MEDICAL & MENTAL HEALTH INTAKE FORM
Name
*
First
Last
Date of Birth
*
Email Address
*
Phone Number
*
1. MENTAL & EMOTIONAL HEALTH HISTORY
Please tick all that apply (Past or Present):
*
Depression
Anxiety / Panic attacks
PTSD / Trauma
OCD
Bipolar (Type I / Type II)
Psychosis or hallucinations
Eating disorder
Substance dependency (past or present)
Suicidal ideation (past or present)
Self-harm (past or present)
Postnatal depression
Other
If you select Other. Please specify
2. MEDICAL HISTORY
Please disclose any relevant medical history:
*
Heart or cardiovascular conditions
Epilepsy / seizures
Neurological conditions
Hormonal conditions (e.g. thyroid, PCOS)
Autoimmune conditions
Chronic pain or illness
Liver or kidney conditions
Pregnancy / trying to conceive
Other
If you select Other. Please specify
Do you have a GP or primary medical professional overseeing your care?
*
Yes
No
3. CURRENT & PREVIOUS MEDICATIONS
Please list all medications you are currently taking or have taken in the past.
Medication Name:
*
Dosage (mg):
*
Frequency:
*
Length of time used:
*
Format:
*
Tablet
Capsule
Liquid
(Repeat for each medication)
4. SSRI / PSYCHIATRIC MEDICATION INFORMATION
Name of SSRI(s) or psychiatric medication(s)
*
Current daily dose:
*
How long have you been taking this medication?
*
Tablet
Capsule
Liquid
5. PHYSICAL & NERVOUS SYSTEM SYMPTOMS
(If applicable)
Insomnia
Anxiety
Low mood
Fatigue
Dissociation
Sensory sensitivity
Digestive issues
Headaches
Mood instability
Other
If you select Other. Please specify
6. PLANT MEDICINE EXPERIENCE (IF ANY)
No previous experience
Micro-level experience only
Larger ceremonial experiences
If yes, please briefly describe:
Context (solo / guided / retreat)
Timeframe (approx.)
Describe Here:
7. SUPPORT & STABILITY
I currently have emotional support (partner, family, friend)
I have access to professional support (therapist, coach, GP)
I feel emotionally stable at this time
I understand full disclosure is required for safety
8. ACKNOWLEDGEMENT
I confirm that the information provided is accurate and complete
I understand this form is for screening and safety purposes only
I agree to communicate openly and honestly
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